Pulmonic Stenosis

Report:

Sinus rhythm

Right axis deviation +140o

Right bundle branch block

Probable right ventricular hypertrophy

Comment:

The congenital PS was repaired 21 years previously; a late sequel was a right ventricular aneurysm, scheduled for elective repair later in the year.

The RVH could be inferred from the large-amplitude QR RBBB morphology in V1 and the marked RAD. The P waves are not helpful; there is, in fact, a soupçon of P-mitrale in Lead 1. Both surgery and RBBB (itself often resulting from surgery) can modify the ECG to the extent that conduction problems mask the underlying chamber hypertrophy. The sometimes used criterion of R wave in V1 > 15 mm has been rightly criticised by Schamroth104.

The Q wave is unusually deep and broad in V1 and the subsequent R wave is 0.12” long. A qR complex of normal duration is very specific for RVH in both children and adults; here one has to admit to some uncertainty.

In pulmonary stenosis the precordial T wave inversion goes much further to the left than in, say, tetralogy of Fallot.

Below (Fig 146a) is another RVH, with much smaller voltages, from a 60 year old lady with primary pulmonary hypertension. The intraventricular conduction is normal and the diagnosis clear-cut: RAD, RAA (in V2), qR in V1.